TRAUMATIC MACULAR HOLES SECONDARY TO COMBAT OCULAR TRAUMA

Multi-layer internal limiting membrane plug technique for management of large full-thickness macular holes

Background

To evaluate the efficacy of the multi-layer internal limiting membrane plug (MIP) technique in promoting the closure of large full-thickness macular holes (FTMH) and improvement of visual function.

Methods

A prospective interventional non-comparative consecutive case series including patients with surgically naïve large FTMH whether primary or secondary. All macular holes were > 400 µm. All patients had 23-gauge pars plana vitrectomy (PPV), MIP technique, and sulfur hexafluoride (SF6) 20% gas tamponade. The main outcome measures were the closure of the hole, improvement of best-corrected visual acuity (BCVA), and detection of complications that might develop due to surgery.

Results

The study included 15 eyes of 15 patients. The mean age was 44 years (range 10–68; SD 21.5). Primary FTMH constituted 53% of cases. The mean pre-operative minimum linear diameter (MLD) was 702 µm (range 401–1068 µm; SD 154). The mean duration of the macular hole was 6 months (range 1–24; SD 6). The mean pre-operative BCVA was 0.06 decimal units (range 0.01–0.1; SD 0.03). Post-operatively, the macular hole was closed in all patients. U- and V- type closure developed in 93% and 7% of patients, respectively. None of the patients developed W-type closure. Post-operatively, the mean post-operative BCVA was 0.2 decimal units (range 0.05–0.5; SD 0.1). The mean improvement was 5 lines of vision. The mean postoperative follow-up period was 4 months (range 1–10; SD 2.5). None of the patients developed complications attributed to the surgical technique described.

Conclusion

MIP technique is effective in promoting macular hole closure and improvement of visual function in large FTMH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40942-022-00428-7.

Primary Lamellar Macular Holes: To Vit or Not to Vit

There is a wide spectrum of macular conditions that are characterized by an irregular foveal contour caused by a break in the inner fovea. These include full-thickness macular hole (FTMH), foveal pseudocyst, lamellar macular hole (LMH) and macular pseudohole (MPH). Clinical examination of vitreomacular interface disorders is notoriously poor in differentiating these conditions. These conditions were initially described with slit-lamp biomicroscopy, and the main goal was to distinguish an FTMH from the others. The introduction of optical coherence tomography (OCT) has revolutionized our understanding of the foveal microstructural anatomy and has facilitated differentiating these conditions from an FTMH. However, the definitions of the other conditions, particularly LMH, has evolved over the past two decades. Initially the term LMH encompassed a wide spectrum of clinical conditions. As OCT became more widely used and observations became more refined, two different phenotypes of LMH became apparent, raising the question of different pathogenic mechanisms for each phenotype. Tractional and degenerative pathological mechanisms were proposed. Epiretinal membranes (ERMs) associated with each phenotype were identified. Typical ERMs were associated with a tractional mechanism, whereas an epiretinal proliferation was associated with a degenerative mechanism. Epiretinal proliferation represents Müller cell proliferation as a reactive process to retinal injury. These two types of ERM were differentiated by their characteristics on SD-OCT. The latest consensus definitions take into account this phenotypic differentiation and classifies these entities into LMH, MPH and ERM foveoschisis. The initial event in both ERM foveoschisis and LMH is a tractional event that disrupts the Müller cell cone in the foveola or the foveal walls. Depending on the extent of Müller cell disruption, either a LMH or an ERM foveoschisis may develop. Although surgical intervention for LMH remains controversial and no clear guidelines exist for pars plana vitrectomy (PPV), eyes with symptomatic, progressive ERM foveoschisis and LMH may benefit from surgical intervention.

Macular Holes: Main Clinical Presentations, Diagnosis, and Therapies

Macular holes are a spectrum of retinal diseases that comprehends full-thickness macular holes (FTMHs), refractory/recurrent macular holes, lamellar macular holes (LMHs), myopic macular holes (MMHs), traumatic macular holes, and macular holes secondary to other retinal pathologies or injuries. There are various classifications of the subtypes of macular hole, and only in recent times researchers defined a common nomenclature, especially thanks to the evolution in retinal imaging, offered by new instruments like the swept-source OCT. The proposed therapies for macular holes are different and range from a “wait-and-see” approach to the vitrectomy, with different results in each subtype of macular hole. This narrative review has the purpose to investigate the available evidence in literature to give a summary of the knowledge about these retinal pathologies.

POSTERIOR SEGMENT INJURIES IN OPERATION IRAQI FREEDOM AND OPERATION ENDURING FREEDOM: 2001 to 2011

BACKGROUND/PURPOSE

To characterize the nature of posterior segment ocular injuries in combat trauma.

METHODS

Eyes in the Walter Reed Ocular Trauma Database were evaluated for the presence of posterior segment injury. Final visual outcomes in open-globe versus closed-globe injuries and by zone of injury and the types of posterior segment injuries in open-globe versus closed-globe injuries were assessed.

RESULTS

Four hundred fifty-two of 890 eyes (50.8%) had at least one posterior segment injury. The mechanism of injury was most commonly an improvised explosive device in 280 (62.0%) eyes. Sixty-one patients (13.5%) had a Zone I injury, 50 (11.1%) a Zone II injury, and 341 (75.4%) a Zone III injury. Patients with Zone I injuries were more likely to have a final visual acuity of 20/200 or better compared with patients with either a Zone II (P < 0.001) or Zone III injury (P = 0.007). Eyes with a closed-globe injury were more likely to have a final visual acuity of 20/200 or better compared with those with an open-globe injury (P < 0.001). Furthermore, closed-globe injury compared with open-globe injury had a lower risk of vitreous hemorrhage (odds ratio 0.32, P < 0.001), proliferative vitreoretinopathy (odds ratio 0.14, P < 0.001), and retinal detachment (odds ratio 0.18, P < 0.001) but a higher risk of chorioretinal rupture (odds ratio 2.82, P < 0.001) and macular hole (odds ratio 3.46, P = 0.004).

CONCLUSION

Patients with combat ophthalmic trauma had similar posterior segment injury patterns to civilian trauma in open-globe versus closed-globe injuries. Zone II and III injuries were associated with a worse visual prognosis.

Cell composition at the vitreomacular interface in traumatic macular holes

Purpose

To describe characteristics of the vitreomacular interface (VMI) in traumatic macular holes (TMH) compared to idiopathic macular holes (IMH) using immunofluorescence and electron microscopy, and to correlate with clinical data.

Methods

For immunocytochemical and ultrastructural analyses, premacular tissue with internal limiting membrane (ILM) and epiretinal membrane (ERM) was harvested during vitrectomy from 5 eyes with TMH and 5 eyes with IMH. All specimens were processed as flat mounts for phase-contrast microscopy, interference and fluorescence microscopy, and transmission electron microscopy (TEM). Primary antibodies were used against microglial and macroglial cells. Clinical data was retrospectively evaluated.

Results

Surgically excised premacular tissue of eyes with TMH showed a less pronounced positive immunoreactivity for anti-glutamine synthetase, anti-vimentin and anti-IBA1 compared to eyes with IMH. Cell nuclei staining of the flat-mounted specimens as well as TEM presented a lower cell count in eyes with TMH compared to IMH. All detected cells were found on the vitreal side of the ILM. No collagen fibrils were seen in specimens of TMH. According to patients’ age, intraoperative data as well as spectral-domain optical coherence tomography (SD-OCT) analysis revealed an attached posterior vitreous in the majority of TMH cases (60%), whereas all eyes with IMH presented posterior vitreous detachment.

Conclusion

The vitreomacular interface in TMH and IMH shows significant differences. In TMH, glial cells are a rare finding on the vitreal side of the ILM.

SURGICAL MANAGEMENT OF TRAUMATIC MACULAR HOLE: Optical Coherence Tomography Features and Outcomes

PURPOSE

To report the outcomes of eyes receiving surgical management for traumatic macular holes. To describe the preoperative and postoperative optical coherence tomography features of traumatic macular holes and to explore associations between preoperative clinical and optical coherence tomography features, and visual outcome.

METHODS

Retrospective study of patients undergoing vitrectomy for traumatic macular hole and entered into the Australian and New Zealand Society of Retinal Specialists surgical registry. Preoperative clinical data, surgical details, and 3-month postoperative outcomes were recorded prospectively. Longer-term outcomes at 12 months were requested retrospectively, as were preoperative and postoperative optical coherence tomography scans.

RESULTS

Hole closure was achieved in 91% (21/23) of patients with a single procedure. The average preoperative visual acuity was 20/120. At 3 months postoperatively, the mean visual acuity had improved to 20/70 (P < 0.001), 11/23 (48%) of eyes improved ≥15 letters, and the number of eyes with 20/40 acuity or better increased from 1/23 to 7/23. Eyes with worse visual outcomes (visual acuity < 20/80) had larger holes, worse preoperative acuity, and a greater extent of preoperative ellipsoid band attenuation than those with better postoperative visual acuity.

CONCLUSION

Eyes receiving surgical management for traumatic macular hole achieved good anatomical results and approximately half had a substantial improvement in acuity. Ellipsoid band attenuation on preoperative optical coherence tomography and worse preoperative acuity were associated with poorer visual outcomes.

Etiologies, Characteristics, and Management of Pediatric Macular Hole

PURPOSE

To report on the etiologies and prognosis of macular hole (MH) in children and to explore the indicators of spontaneous hole closure and poor final visual outcome (vision worse than 20/200).

DESIGN

Consecutive, retrospective case series.

METHODS

A consecutive series of patients aged less than 16 years with a full-thickness macular hole treated from 2013 to 2019 in a singer tertiary center was retrospectively reviewed. Data collected from charts included age, sex, best-corrected visual acuity (BCVA), etiology of MH, size of MH, clinical findings, operations, and anatomic and functional outcomes. Logistic regression models were built to establish the predisposing factors.

RESULTS

Forty eyes of 40 patients were included. Patients were predominantly male with a mean age of 8.3 years. Among the etiologies, trauma prevailed in 29 (72.5%) eyes. Twenty-nine patients underwent surgery, and 18 (62.1%) had traumatic MH. All had achieved hole closure. BCVA improved at the final visit. Spontaneous closure was found in 10 (25%) eyes after an average 2 months after trauma. Regression analysis showed that a relatively smaller macular hole (P = .006) was likely to experience spontaneous closure. Presence of macular lesions (P = .001) was identified as risk factor for poor final vision.

CONCLUSIONS

Most pediatric MH was caused by blunt trauma. BCVA improved after MH closed, regardless of surgery or spontaneous closure. Smaller MH secondary to trauma was more likely to experience spontaneous closure with an average time of 2 months. Presence of macular lesions was a risk factor for final poor vision.

Optical Coherence Tomography Morphological Features Following Modified Internal Limiting Membrane Surgical Technique In Traumatic Macular Holes

Objective

To describe the optical coherence tomography (OCT) findings in terms of macular hole closure and ellipsoid zone (EZ) recovery following modified internal limiting membrane (ILM) surgical technique in traumatic macular holes (TMH).

Methods

The study was a retrospective case series that recruited 16 consecutive patients with TMH. Following vitrectomy (PPV), we performed modified ILM surgical technique (IFT) in which ILM peel was stopped at the edges of the hole forming a floating ILM flap. Primary outcome measures were pattern of TMH closure and recovery of EZ. Student’s T-test and Pearson’s correlation coefficient were used for statistical analysis.

Results

The study had 16 eyes of 16 patients. Mean baseline minimum linear diameter (MLD) was 562µ. Mean baseline best-corrected visual acuity (BCVA) was 1.4 logMAR. U-pattern closure occurred in 50% of eyes, V-pattern closure occurred in 31.2% of eyes, whereas W-pattern closure occurred in 18.7% of eyes. Mean BCVA improvement was 5 lines (p 0.02). Failure of recovery of EZ was detected in 75% of eyes. In the present series, neither pre-operative MLD nor time lapse prior to surgery were significant factors in determining the closure pattern of TMH, the grade of EZ recovery or final BCVA.

Conclusion

Modified IFT is effective in promoting macular hole closure and improving visual acuity in patients with TMH. The technique does not promote recovery of EZ.

Comparative Study between Pars Plana Vitrectomy with Internal Limiting Membrane Peel and Pars Plana Vitrectomy with Internal Limiting Membrane Flap Technique for Management of Traumatic Full Thickness Macular Holes

Purpose

To compare the efficacy of PPV and ILM peel versus PPV and IFT in patients with traumatic FTMH.

Methods

Retrospective interventional comparative case series including two groups of patients with traumatic FTMH. Patients were divided into group I (ILM peel) and group II (IFT). The main outcome measure was closure of the macular hole and restoration of the foveal microstructure. The independent-samples T-test and ANOVA test were used to study the mean between 2 groups and calculate the P value, whereas the bivariate correlation procedure studied the interaction between the variables tested.

Results

Group I included 28 patients. Mean preoperative MLD was 757 µm. Mean preoperative BCVA was approximately 20/320. Group II included 12 patients. Mean preoperative MLD was 529.5 µm. Mean preoperative BCVA was 20/320. Group I had a macular hole closure rate of 75% versus 92% in group II P=0.05. Mean BCVA improvement was 2.5 lines in group I versus 5 lines in group II P=0.02. Disrupted ELM and IS/OS was the most salient finding in both groups.

Conclusion

IFT has a significantly superior anatomic and functional outcome compared to ILM peel in traumatic FTMH.

Lamellar Macular Hole: State of the Art

Lamellar macular hole (LMH) is a vitreoretinal disorder characterized by an irregular foveal contour, a break in the inner fovea, dehiscence of the inner foveal retina from the outer retina, and the absence of a full-thickness foveal defect with intact foveal photoreceptors. The pathogenesis is only partially known. The advent of high-resolution optical coherence tomography has allowed distinguishing between two types of epiretinal membrane (ERM) associated with LMH: a conventional ERM (commonly found in macular pucker) and an atypical ERM (known by varied names: dense, epiretinal proliferation, or degenerative). These two types of ERM not only influence LMH morphology but also differ in cell and collagen composition. It remains unclear if these two types are indeed two distinct clinical entities or rather two stages of the same macular disorder. Studies of the natural evolution of LMH have not fully resolved this issue and also offered variable results. Surgical treatment leads to excellent anatomical and functional outcomes, but not without risks. This review provides a critical summary of the available data on LMH including some new insights.

Closed globe macular injuries after blasts in combat

PURPOSE

To describe the macular findings after closed globe ocular injuries sustained from blasts.

METHODS

A retrospective chart review from February 2003 to March 2010 of all soldiers with closed globe ocular injuries sustained during combat with macular findings of trauma on examination was completed.

RESULTS

There were 36 eyes that met the inclusion criteria. The mean age of the soldiers was 29.5 years and 97% were men. The average follow-up time was 18.6 months. Improvised explosive device blasts accounted for 86% of injuries. Forty-five percent of soldiers had bilateral ocular injuries. Eight of 36 eyes (22.2%) developed a macular hole. One eye had spontaneous closure and five eyes underwent surgical repair. There was a range of macular findings from retinal pigment epitheliopathy alone to retinal pigment epitheliopathy with full-thickness atrophy. Eight eyes (22.2%) had macular scarring on examination but no optical coherence tomography study. One eye (2.8%) developed phthisis bulbi. Fifteen eyes (42%) had an orbital fracture. Seven eyes (19%) sustained optic neuropathy.

CONCLUSION

Closed globe injuries after blasts resulted in a spectrum of macular findings. The integrity of the foveal inner segment/outer segment junction was the most important retinal factor in visual outcomes. Orbital fractures were not found to be a risk factor for developing optic neuropathy and may improve visual outcomes. The rate of long-term complications is unknown, and it is important for ophthalmologists to follow these patients closely.